Current Job Openings >> Utilization Reviewer RN
Utilization Reviewer RN
Summary
Title:Utilization Reviewer RN
ID:UM18
Location:Rochester
Job Type:Temporary (Full-time)
Date Posted:10/10/2018
Openings:1
Department:Utilization Management
Description

This is a full-time, long term temporary assignment

GRADE:
307

POSITION SUMMARY
Facilitates the effective utilization of health care resources to optimize member health care outcomes.   Enhance access to care and service while maintaining maximum quality and service value.   Reviews requests for referrals, prior authorizations and claims adjustments to determine whether health care services that have been provided, are being provided, or are proposed to be provided to a member are medically necessary or experimental /investigational.

POSITION HAS DIRECT REPORTS: No


ESSENTIAL JOB DUTIES/FUNCTIONS

 
% of Time
 
 Essential Function



 
75
 Utilization Review Functions

 
- Perform utilization review activities including prospective, concurrent and retrospective reviews.

 - Review pended claims for clinical appropriateness of services.

 - Make recommendations for approval or denial of services within established time frames.

 - Maintain appropriate documentation and records of activities.
 
15
 Work in collaboration with others to gather information relating to all service requests in a timely manner.
 
10
 Identification

 
- Identify members who could benefit from case management, social work and/or outreach services to optimize health care outcomes and refer to appropriate staff.

OTHER FUNCTIONS AND RESPONSIBILITIES

- Serve as a resource to Monroe Plan staff regarding service utilization.
- Participate in program development and modification in conjunction with appropriate Monroe Plan staff based on utilization program performance and clinical best practices.
- Attend and participate in in-service training/meetings.
- Foster a positive working relationship with providers and Monroe Plan staff.
- Support team member cross coverage as work load dictates.
- Demonstrate flexibility in assuming other job responsibilities as program and organization needs change.
- Adhere to Monroe Plan professional boundaries and protocols.
- Ensure compliance with appropriate confidentiality and other required regulations.Perform other duties as assigned.
- Performs other duties as assigned.
 
Position Limitations:
 
- Cannot perform any tasks which are outside scope of practice.
- Cannot transport active Monroe Plan members at any time.
- Cannot make any modifications or suggestions RE: treatment or medication regimen to members.
- Cannot perform hands-on care.

MINIMUM REQUIREMENTS/LICENSES/CERTIFICATIONS
Medical

- Must possess a current NYS RN license.
- Minimum of 2 years in general medicine/surgery/home care required.
 
Behavioral Health
 
- Must possess either a current LCSW or a current NYS RN license.
- Minimum of 3 years experience in the Behavioral health field required.
- Excellent communication skills; both oral and written as well as strong interpersonal skills.
- Demonstrated understanding of utilization management, treatment and discharge planning.
- Ability to work independently.
- Strong organizational skills.
- Strong computer and typing skills.

PREFERRED QUALIFICATIONS

- BSN preferred for both positions.
- Prior Utilization Management experience a plus.
This opening is closed and is no longer accepting applications
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